For your convenience, the following forms are available to view, download and complete. Save some time and bring the form with you at your next visit, or mail the form back to us.
New Patients & Common Forms
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Patient Guide
This handout contains important information for services at WPMB. It includes the following sections and materials:
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Consent to Share Information
Use this form to authorize Woodcreek Pediatrics - Mary Bridge Children's to share various types of protected health information with individuals you choose. |
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Pre-Participation/Physical History Form
This form is to be filled out by the patient or parent prior to each annual well child exam for all children ages 11 and older. Developed by a coalition of 6 leading medical societies, the Pre-participation Physical Evaluation History Form is a screening tool to help identify diseases or processes that may affect an athlete’s participation in physical activity. The questions are designed to assess the athlete’s (or active person’s) general medical history and probe potential issues related to cardiovascular problems, the central nervous system, pulmonary system, gastrointestinal/genitourinary systems, dermatologic conditions, musculoskeletal concerns, and the female athlete. The completed form will be kept in the child’s medical record for any future activity requiring a physical prior to participation (e.g., sports, camp, etc.). |
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Special Consent Forms
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Release of Information Form
Use this form to authorize Woodcreek Pediatrics - Mary Bridge Children's to exchange or share medical records with other healthcare providers, individuals or to request copies of a medical record. This form is also called the Authorization to Use or Disclose Protected Health Information. The completed form can be dropped off at any of our locations or faxed to our medical records department at (253) 864-3917. |
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Advanced Consent to Treat a Minor Form
Allow a individual to authorize and consent to routine and emergency medical treatment for a child. This form allows the parent/guardian to provide consent for their children (under 18) to be treated without the parent/guardian present. |
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Authorization for Healthcare of a Minor Form
Parents or guardians can temporarily trust decisions about their child's medical treatment to a babysitter, relative or other temporary caregiver. This form allows specified caregivers to access medical care for the child without delay, especially during emergencies. |
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